PERSONAL INJURY PATIENT HISTORY FORM

PERSONAL INJURY PATIENT HISTORY FORM NAME DATE AUTOMOBILE ACCIDENT INSURANCE INFORMATION Insurance Company Name Claim #: Adjuster s Name Phone # Agent s Name Phone # HISTORY OF OCCURRENCE 1. Date of accident Time AM/PM Driver of Vehicle 2. Where were you seated? Drivers seat Front right passenger Front center passenger Rear left passenger Rear center passenger Rear right passenger 3. Who owns the car? Year and model of car 4. Description of other vehicle involved in accident 5. What was the damage done to the car you were in? Mild Moderate Severe Total Unknown 6. Visibility at the time of the accident was: Poor Fair Good 7. The road conditions at the time of the accident were: Snow/Icy Wet Clear Dark 8. Type of accident: Was hit in the.. Hit another car in the.. Rear Right side Left side Front 9. If this was not a collision, please describe IMPACT/SEAT BELT/HEADREST/SPEED 10. Describe in your own words what happened to you upon impact: 11. Were you aware the accident was about to happen? Yes No 12. Did you brace for the impact? Yes No 13. Were you wearing a seat belt? Yes No Shoulder harness? Yes No 14. Did the car you were in have a headrest? Yes No If yes, what was the position of the headrest compared to your head before the accident? Top of headrest even with bottom of the head Top of headrest even with top of head Top of headrest even with middle of the neck 15. Was the car equipped with an airbag where you were seated? Yes No If yes, did the airbag inflate? Yes No Were you injured by the inflated airbag? Yes No If yes, what were the injuries? 16. Was your car braking? Yes No 17. Was your car moving at the time of the accident? Yes No If yes, how fast would you estimate you were going? MPH (estimate) 18. How fast was the other car going? MPH (estimate) Don t know HEAD AND BODY POSITION/ ABILITY TO MOVE BODY 19. Head and body position at the time of impact was: Head turned: Right Left Head looking back Head straight forward Body straight in sitting position Body rotated: Left Right 20. At the time of the accident, what parts of your head or body hit what parts on the inside of your car? 21. As a result of the accident you were: Rendered unconscious Dazed, circumstances vague Shaken up but could think clearly and function 22. Could you move all parts of your body? Yes No If no, what body parts could you not move, and why? 23. Were you able to get out or the car and walk unaided? Yes No If no, why not? 24. Did you receive any medical assistance at the scene of the accident? Yes No Page 1 of 5

Illustrate below how the accident happened: SYMPTOMS FROM ACCIDENT 25. Did you get any bleeding cuts? Yes No If yes, where? 26. Did you get any bruises: Yes No If yes, where? 27. Please describe how you felt: Immediately after the accident Later that day The next days 28. Check symptoms apparent since the accident: Headache Neck pain/stiffness Mid-back pain Low-back pain Eyes light sensitive Pain behind eyes Dizziness Fainting Sleeping problems Fatigue Numbness in fingers Numbness in toes Loss of smell Loss of taste Loss of memory Loss of balance Breath shortness Ringing/Buzzing Irritability Depression Cold hands Cold feet Diarrhea Constipation Tension Nervousness Anxious Cold sweats Chest pain Facial pain Clicking or Popping Jaw Other 29.What makes your condition worse? Nothing Lifting Trying to stand Standing Walking Sitting Movement Exercise Inactivity Work activities Home activities Other 30.What makes your condition better? Nothing Standing Walking Sitting Movement Exercise Inactivity Lying down Sleep Hot shower/bath Ice Stretching Other 31.What is your ability to perform the following activities? U=unable, P=painful, L=limited, N=normal Coughing or sneezing Getting in or out of a car Bending over forward Putting on clothes Putting on shoes Turning over in bed Getting out of bed Lying flat on stomach Lying on side with knees bent Climbing Kneeling Balancing Looking back Stooping Gripping Pushing Pulling Reaching 32.Describe your complaints, name the body parts: Character Pain Spasm Tender Sore Ache Stiff Shooting Weak Numb Symptoms are BETTER in AM Midday PM Symptoms are WORSE in AM Midday PM Symptoms do not change with time of day Page2 of 5

Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Mark stress points of radiation. Include all affected areas. X numbness + burning O pin & needles = stabbing On a scale of 0-10, with 0 being pain free and 10 being excruciating pain, where would you rate the intensity of your pain? I==================================================I 0 1 2 3 4 5 6 7 8 9 10 WORK STATUS/HISTORY 33. Occupation: Employer: 34. Have you missed time from work? Yes No If yes, unable to work since the accident If yes, full time off work from to If yes, part time off work from to 35. Did you seek medical help immediately after the accident? Yes No If yes, how did you get there? Ambulance Police Someone else drove me Drove own car Other 36. FIRST DOCTOR/HOSPITAL/CLINIC SEEN Name: Date of first visit: Were you examined? Yes No Were x-rays taken? Yes No Did you receive treatment? Yes No If yes, what kind of treatment did you receive? What benefits did you receive from the treatment? Date of last treatment 37. SECOND DOCTOR/HOSPITAL/CLINIC SEEN Name: Date of first visit: Were you examined? Yes No Were x-rays taken? Yes No Did you receive treatment? Yes No If yes, what kind of treatment did you receive? What benefits did you receive from the treatment? Date of last treatment PRIOR SIMILAR SYMPTOMS 38. Did you have any physical complaints just before the accident? Yes No If yes, what physical symptoms did you have just before the accident? 39. Prior to this accident, have you EVER had symptoms similar to what you are experiencing now? Yes No If yes, please explain(briefly include past falls, injuries, accidents, operations, etc.) PAST MEDICAL HISTORY 40. Please check all that apply None related to current complaints Hospital or operation Auto accident Work accident Illness Other Page 3 of 5

Describe 41. Family History Please check if any family member has had: Tuberculosis Kidney disease Spinal disorder Mental illness Epilepsy Diabetes Gout Allergy Arthritis Hypertension Cancer Migraines Heart attack Other, list: 42. Are you pregnant? Yes No Not sure 43. Please list any medications you are currently taking ACTIVITIES OF DAILY LIVING ASSESSMENT The following questions are designed to give the doctor information as to how your pain has affected your ability to manage in everyday life. Please check one item in each section that most closely applies to you. SECTION 1: PAIN INTENSITY I can tolerate the pain I have without using painkillers The pain is bad, but I mange without taking painkillers Painkillers give complete relief form pain Painkillers give moderate relief from pain Painkillers give very little relief from pain Painkillers give no relief from pain and I do not use them SECTION 2: PERSONAL CARE (washing, dressing, etc.) I can look after myself normally without causing extra pain I can look after myself normally, but it causes extra pain It is painful to look after myself and I am slow and careful I need some help, but manage most of my personal care I need help every day in most aspects of self care I do not get dressed, wash with difficulty, and stay in bed SECTION 3: LIFTING I can lift heavy weights without extra pain I can lift heavy weights, but it causes extra pain Pain prevents me from lifting heavy weights off the floor, but I can manage if the are on a table Pain prevents me from lifting heavy weights, but I can manage light to medium weights I can lift only very light weights I cannot lift or carry anything at all SECTION 4: WALKING Pain does not prevent me from walking any distance pain prevents me from walking more than one mile Pain prevents me from walking more than ½ mile Pain prevents me from walking more than ¼ mile I can only walk using a cane or crutches I am in bed most of the time and have to crawl to the toilet SECTION 5: SITTING I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me from sitting for more than one hour Pain prevents me from sitting for more than 30 minutes Pain prevents me from sitting for more than 10 minutes Pain prevents me from sitting at all SECTION 6: STANDING I can stand as long as I want without extra pain I can stand as long as I want, but it causes extra pain Pain prevents me from standing for more than one hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all Page 4 of 5

SECTION 7: SLEEPING Pain does not prevent me from sleeping well I can sleep well only by using tablets Even when I take tablets I have less than 6 hours sleep Even when I take tablets I have less than 4 hours sleep Even when I take tablets I have less than 2 hours sleep Pain prevents me from sleeping at all SECTION 8: SEX LIFE My sex life is normal and causes no extra pain My sex life is normal and causes some extra pain My sex life is nearly normal, but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all SECTION 9: SOCIAL LIFE My social life is normal and gives me no extra pain My social life is normal, but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain SECTION 10: TRAVELING I can travel anywhere without extra pain I can travel anywhere, but it gives me extra pain Pain is bad, but I manage journeys over 2 hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary trips under a half hour Pain restricts me from traveling except to the doctor or hospital Do you have an attorney on this claim? Yes No If yes, who? Phone #: Patients involved in litigation (law suits) or third party payment are ultimately responsible for payment for services. I authorize the release of any medical or other information necessary to process my insurance claim. This is to serve as a long-term authorization card. MY SIGNATURE IS AN ACKNOWLEDGMENT THAT I HAVE READ THE ABOVE, AND AGREE TO ABIDE BY SAME. Patient Signature Date GUARDIAN SIGNATURE (If patient is under 18) Page 5 of 5